Boat Insurance Claim Form

The issue or acceptance of this form is not to be construed as an admission of liability on the part of the Company. Please provide complete details to the questions asked on this form. If there is insufficient space for your answers please use the Additional Information section on the back of this form.

The issue or acceptance of this form is not to be construed as an admission of liability on the part of the Company.

Please provide complete details to the questions asked on this form. If there is insufficient space for your answers please use the Additional information section of this form.

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1. Your Details

Policy Number*

Expiry Date*

Name of Insured*

FirstLast

Your Email

Best contact number

Postal Details

Postal Address*

Suburb*

Post Code*

State*

Authorised Contact

Contact Name*

FirstLast

Best Contact Number*

Email*

Relationship with you

2. Goods and Services Tax

Are you registered for GST?*

ABN Number*

What is your entitlement to an input Tax Credit in respect of:

Your boat insurance premium

Please enter a value less than or equal to 100.

The property that is the subject of this claim

Please enter a value less than or equal to 100.

3. Your Boat Details

Make

Model

Motor

Serial Number

Trailer Brand

Registration

4. Type of Claim

Claim Type*

Collision

Theft

Fire

Malicious Damage

Storm

Sinking

Transit Damage

Liability

Other

Please specify claim type

5. Incident Details

Date of Occurance*

Time

:HH

MM

Where did the incident occur?*

State*

Please describe what happened*

What Happened Photos

2MB file size limit (per file)

Photo 1

Photo 2

Photo 3

Photo 4

Photo 5

Was the boat being used for a race / speed trial?*

No

Yes

Was the race / speed trial a...

What was the length of the race?

What purpose was your boat being used for?

Please provide details

Speed of boat at the time of incident

What were the weather conditions at the time of the incident:

Visibility

Water

Wind

6. Own Damage and Liability Claims

Name of person operating the boat

FirstLast

Postal Details

Postal Address

Suburb

Post Code

State

Home Phone Number

Work / Mobile Number

Boat Licence Number

Expiry Date

Date of Birth

Boating Experience

What is the relationship of this person to the insured?

Is it alleged that any person involved in this incident was under the influence of alcohol or a drug?

7. Theft Claims

Section applicable only to theft claims.

Where was the property being claimed for stolen from?*

Was there evidence of forcible entry or removal?*

Yes

No

How did they gain entry or remove the property being claimed?*

8. Police/Authorities - All incidents

Have you reported the incident to police?*

Yes

No

Provide Details

Police Station*

Date Reported*

Time Reported*

:HH

MM

Attach Copy of Police Report

2MB file size limit

If this incident involves a race or speed trial where a protest was lodged please advise the outcome of that protest

9. Loss Reduction/Salvage

Have you taken any other action to recover or reduce your loss?*

Yes

No

If yes, give details*

10. Other Parties

Was an other party/other parties injured or their property damaged in this incident?*

Yes

No

If yes, please provide details.

Other party 1

Name

FirstLast

Address

Post Code

State

Phone Number

Other party 2

Name

FirstLast

Address

Post Code

State

Phone Number

If this incident involved another boat or vehicle please provide:

Boat/Vehicle 1

Make

Model

Registration No

Colour

Name of Insurer

Boat/Vehicle 2

Make

Model

Registration No

Colour

Name of Insurer

Please advise the extent of damage or injuries sustained

Who do you consider responsible for this incident?

Why do you consider this person responsible?

11. Witnesses

Were there any witnesses?*

Yes

No

Witness 1

Name

FirstLast

Phone Number

Postal Address

Post Code

State

Witness 2

Name

FirstLast

Phone Number

Postal Address

Post Code

State

12. Ownership and Other Insurance

Are you the sole owner of the lost or damaged property?*

Yes

No

If no, provide details*

Are you able to make a claim with another insurance company for any of the property you are claiming now?*

Yes

No

If yes, provide details

Name of Insurer*

Policy Number*

13. Insured's History

Have you ever...

Had previous claims?

Yes

No

Been refused insurance?

Yes

No

Been charged/convicted of any offence?

Yes

No

If you answered Yes to any of the above provide details

14. Schedule

Please provide full details of your loss. If there is insufficent space below please show additional details at the end of this claim form.

Item 1:

Description of Property - Lost/damaged/stolen

Year Purchased

Estimate Value

Cost of Repairs (if damaged)

Receipts/Quotes

2MB file size limit

Item 2:

Description of Property - Lost/damaged/stolen

Year Purchased

Estimate Value

Cost of Repairs (if damaged)

Receipts/Quotes

2MB file size limit

Item 3:

Description of Property - Lost/damaged/stolen

Year Purchased

Estimate Value

Cost of Repairs (if damaged)

Receipts/Quotes

2MB file size limit

Item 4:

Description of Property - Lost/damaged/stolen

Year Purchased

Estimate Value

Cost of Repairs (if damaged)

Receipts/Quotes

2MB file size limit

15. Claims Procedure

What you need to do:

Take every reasonable precaution to prevent further loss, damage, cost or liability;

Notify the police as soon as possible if the incident involves injury, theft, attempted theft, malicious acts, or impact by a boat or vehicle;

Notify us as soon as possible about the claim;

Assist us to manage the claim. This may include us inspecting your boat, interviewing you, or you providing written statements to us under oath;

Provide us with all reasonable proof that we require in respect of lost or damaged items claimable under this policy;

Keep items that have been damaged and make them available for inspection or assessment of repair costs;

Allow us to take possession of damaged property that is the subject of a claim.

You must not:

Admit guilt, fault, or liability (except to the Police);

Approve any repairs or arrange replacements (other than emergency repairs reasonably necessary to protect your boat against further loss or damage);

Dispose of any damaged property.

Summary

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16. Declaration

I/We will notify Nautilus Marine immediately where this claim is for lost or stolen property and any of it is found.

I/We certify that the information given in this form is truthful accurate and complete. No information likely to affect this claim has been withheld.

I/We understand that this claim may be refused if information is untrue, inaccurate or concealed.

I/We authorise Nautilus Marine to give to, or obtain from, other insurers or any insurance reference bureau, any information relating to this claim or any other claim made by me/us or any insurance held by me/us.

Signature of Insured/s

2MB file size limit

Date

Signature of Insured/s

2MB file size limit

Date

Additional Information

Please use this area to provide any additional details in relation to this incident.

Details of incident

Please upload a Diagram of Incident

Incident Diagram

2MB file size limit

You have come to the end of the form.
Please review all details carefully and click the "Submit Form" button to complete your claim.

Confirmation*

By checking this box, you confirm that you understand that the submit button acts as your signature when submitting the claim online.

Any advice given on this website is general only and may not be right for you.
To decide if an insurance product is right for you please carefully read the relevant Product Disclosure Statement. The relevant PDS is available here.

About the Insurers:

The underwriter of this insurance is AIG Australia Limited (“AIG Australia”) (ABN 93 004 727 753) (AFSL 381686).
AIG is the marketing name for the worldwide property-casualty, life and retirement, and general insurance operations of American International Group, Inc.

About Nautilus and its services:

NM Insurance Pty Ltd (ABN 34 100 633 038 AFSL 227 186) trading as Nautilus Marine Insurance of 3/97-99 Bathurst St, Sydney NSW 2000 is the administrator of this insurance as agent for the Insurers. Nautilus has been given a binding authority by the Insurers which allows it to enter into policies and handle and settle claims for them, subject to the terms of the binder authority. In dealing with policies, Nautilus acts for the Insurers and not you.